Abstract

The most difficult clinical questions in stroke rehabilitation are “What is this patient’s potential for recovery?” and “What is the best rehabilitation strategy for this person, given her/his clinical profile?” Without answers to these questions, clinicians struggle to make decisions regarding the content and focus of therapy, and researchers design studies that inadvertently mix participants who have a high likelihood of responding with those who do not. Developing and implementing biomarkers that distinguish patient subgroups will help address these issues and unravel the factors important to the recovery process. The goal of the present paper is to provide a consensus statement regarding the current state of the evidence for stroke recovery biomarkers. Biomarkers of motor, somatosensory, cognitive and language domains across the recovery timeline post-stroke are considered; with focus on brain structure and function, and exclusion of blood markers and genetics. We provide evidence for biomarkers that are considered ready to be included in clinical trials, as well as others that are promising but not ready and so represent a developmental priority. We conclude with an example that illustrates the utility of biomarkers in recovery and rehabilitation research, demonstrating how the inclusion of a biomarker may enhance future clinical trials. In this way, we propose a way forward for when and where we can include biomarkers to advance the efficacy of the practice of, and research into, rehabilitation and recovery after stroke.

Introduction

Stroke is a heterogeneous condition, making choice of treatment, and prediction of outcome and treatment response, difficult. Despite this, clinical trials are often designed with a ‘one size fits all’ point of view, which can make them vulnerable to patient heterogeneity, reduced statistical power, and thus failure. Biomarkers can greatly inform patient selection for trials in general medical research, and this is equally true for stroke recovery. A stroke recovery biomarker (SRB) can be defined as an indicator of disease state that can be used as a measure of underlying molecular/cellular processes that may be difficult to measure directly in humans, and could be used to understand outcome, or predict recovery or treatment response.1

In practical terms, biomarkers should improve our ability to predict long-term outcomes after stroke across multiple domains. This is beneficial for: (a) patients, caregivers and clinicians; (b) planning subsequent clinical pathways and goal setting; and (c) identifying whom and when to target, and in some instances at which dose, with interventions for promoting stroke recovery.2 This last point is particularly important as methods for accurate prediction of long-term outcome would allow clinical trials of restorative and rehabilitation interventions to be stratified based on the potential for neurobiological recovery in a way that is currently not possible when trials are performed in the absence of valid biomarkers. Unpredictable outcomes after stroke, particularly in those who present with the most severe impairment3 mean that clinical trials of rehabilitation interventions need hundreds of patients to be appropriately powered. Use of biomarkers would allow incorporation of accurate information about the underlying impairment, and thus the size of these intervention trials could be considerably reduced,4 with obvious benefits. These principles are no different in the context of stroke recovery as compared to general medical research.5

Interventions fall into two broad mechanistic categories: (1) behavioural interventions that take advantage of experience and learning-dependent plasticity (e.g. motor, sensory, cognitive, and speech and language therapy), and (2) treatments that enhance the potential for experience and learning-dependent plasticity to maximise the effects of behavioural interventions (e.g. pharmacotherapy or non-invasive brain stimulation).6 To identify in whom and when to intervene, we need biomarkers that reflect the underlying biological mechanisms being targeted therapeutically.

Our goal is to provide a consensus statement regarding the evidence for SRBs that are helpful in outcome prediction and therefore identifying subgroups for stratification to be used in trials.7 We focused on SRBs that can investigate the structure or function of the brain (Table 1). Four functional domains (motor, somatosensation, cognition, and language (Table 2)) were considered according to recovery phase post stroke (hyperacute: <24 h; acute: 1 to 7 days; early subacute: 1 week to 3 months; late subacute: 3 months to 6 months; chronic: > 6 months8). For each functional domain, we provide recommendations for biomarkers that either are: (1) ready to guide stratification of subgroups of patients for clinical trials and/or to predict outcome, or (2) are a developmental priority (Table 3). Finally, we provide an example of how inclusion of a clinical trial-ready biomarker might have benefitted a recent phase III trial. As there is generally limited evidence at this time for blood or genetic biomarkers, we do not discuss these, but recommend they are a developmental priority.9–12 We also recognize that many other functional domains exist, but focus here on the four that have the most developed science. […]

Summary

During the past ten years, an increasing number of controlled studies have assessed the potential rehabilitative effects of music-based interventions, such as music listening, singing, or playing an instrument, in several neurological diseases. Although the number of studies and extent of available evidence is greatest in stroke and dementia, there is also evidence for the effects of music-based interventions on supporting cognition, motor function, or emotional wellbeing in people with Parkinson’s disease, epilepsy, or multiple sclerosis. Music-based interventions can affect divergent functions such as motor performance, speech, or cognition in these patient groups. However, the psychological effects and neurobiological mechanisms underlying the effects of music interventions are likely to share common neural systems for reward, arousal, affect regulation, learning, and activity-driven plasticity. Although further controlled studies are needed to establish the efficacy of music in neurological recovery, music-based interventions are emerging as promising rehabilitation strategies.

About Me

I am an occupational therapist (OT) who specialized in stroke rehab. I continued my education by having a stroke in 2004 that paralyzed my dominant right side. I still walk with a brace and cane, regained only partial use of my hemiplegic hand, and still have slurred speech when I’m tired.

I live alone so I am both the caregiver and the stroke survivor. I am divorced and was not able to have children. My two middle-aged bachelor brothers live 800 miles away and two life-long friends live 1,200 miles away. My parents are dead. Thank goodness I have a small army of local friends.

I had my stroke a year after I completed my doctorate in cognitive psychology. My stroke rehab felt like my last major learning experience so I wrote a book called My Last Degree: A Therapist Goes Home After a Stroke. My sense of purpose continued to grow as I developed Power Point presentations for stroke survivor support groups, rehab professionals, and OT students. I live in New Jersey, U.S.A. E-mail me at homeafterastroke3@verizon.net.

The 2nd edition has 44 photos that make it easier to understand what I am describing. This edition includes solutions to challenges that occur long after formal rehab is over.

There are reports of Amazon listing books as “out of stock” and imposing long delivery times. You can order this book from the publisher at www.booklocker.com.

Abstract

Objective

To explore motor performance on two different cognitive tasks during robotic rehabilitation in which motor performance was longitudinally assessed.

Design

Prospective study

Setting

Rehabilitation hospital

Participants

Patients with chronic stroke and upper extremity impairment (N=22)

Intervention

A total of 640 repetitions of robot-assisted planar reaching, five times a week for 4 weeks

Main Outcome Measures

Longitudinal robotic evaluations regarding motor performance included smoothness, mean velocity, path error, and reach error by the type of cognitive task. Dual-task effects (DTE) of motor performance were computed in order to analyze the effect of the cognitive task on dual-task interference.

BACKGROUND: Executive function deficits negatively impact independence and participation in everyday life of individuals with chronic stroke. Therefore, it is important to explore therapeutic interventions to improve executive functions.
AIM: The aim of this study was to determine the effectiveness of a 3-month interactive video-game group intervention compared to a traditional motor group intervention for improving executive functions in individuals with chronic stroke.
DESIGN: This study is a secondary analysis of a single-blind randomized controlled trial for improving factors related to physical activity of individuals with chronic stroke. Assessments were administered pre and post the intervention and at 3-month follow-up by assessors blind to treatment allocation.
METHODS: Thirty-nine individuals with chronic stroke with executive function deficits participated in an interactive video-game group intervention (N.=20) or a traditional group intervention (N.=19). The intervention included two 1-hour group sessions per week for three months, either playing video-games or performing traditional exercises/activities. Executive function deficits were assessed using The Trail Making Test (Parts A and B) and by two performance-based assessments; the Bill Paying Task from the Executive Function Performance Test (EFPT) and the Executive Function Route-Finding Task (EFRT).
RESULTS: Following intervention, scores for the Bill Paying Task (EFPT) decreased by 27.5% and 36.6% for the participants in the video-game and traditional intervention, respectively (F=17.3, P<0.000) and continued to decrease in the video-game group with small effect sizes. Effect size was small to medium for the TMT-B (F=0.003, P=0.954) and EFRT (F=1.2, P=0.28), without any statistical significance difference.
CONCLUSIONS: Interactive video-games provide combined cognitive-motor stimulation and therefore have potential to improve executive functioning of individuals with chronic stroke. Further research is needed.
CLINICAL REHABILITATION IMPACT: These findings highlight the potential of utilizing interactive video-games in a small group for keeping these individuals active, while maintaining and improving executive functioning especially for individuals with chronic stroke, who have completed their formal rehabilitation.

Explore the relationship between acupuncture and cognitive therapy with change in cognitive domains following traumatic brain injury. The secondary objective was to evaluate the potential relationship between acupuncture and cognitive therapy with volume activation in select brain areas as shown by functional MRI (fMRI).

Abstract

Nearly 1.7 million Americans sustain a traumatic brain injury (TBI) each year. These injuries can result in physical, emotional, and cognitive consequences. While many individuals receive cognitive rehabilitation from occupational therapists (OTs), the interdisciplinary nature of TBI research makes it difficult to remain up-to-date on relevant findings. We conducted a literature review to identify and summarize interdisciplinary evidence-based practice targeting cognitive rehabilitation for civilian adults with TBI. Our review summarizes TBI background, and our cognitive remediation section focuses on the findings from 37 recent (since 2006) empirical articles directly related to cognitive rehabilitation for individuals (i.e., excluding special populations such as veterans or athletes). This manuscript is offered as a tool for OTs engaged in cognitive rehabilitation and as a means to highlight arenas where more empirical, interdisciplinary research is needed.

Introduction

Imagine this scenario: An occupational therapist (OT) at a rehabilitation hospital receives the schedule for the day. From this list of names, the OT has 30 min to complete a chart review and make treatment plans. For clients with physical injuries, the treatment plan is clear. These patients will work with the OT to increase their limb flexibility, strength, and utility. The OT will provide adaptive equipment to compensate for the physical deficits that cannot be remediated. However, there is one client listed who has a traumatic brain injury (TBI). She needs cognitive rehabilitation so she can return home safely. The OT recognizes that rehabilitation should focus on improving the client’s attention, learning, and memory, but it is not always clear what approach is optimal. The client’s injury is internal and invisible. The OT wants to believe that the activities the client completes will lead to meaningful improvements to her brain function. But is there any certainty of this? Do improvements during acute therapy translate to real-life functionality? At what time point does an OT assume that remediatory approaches are futile, and compensatory interventions are best practice? What factors regarding patient management from other intervention stages must be considered to predict optimal cognitive outcomes? When should rehabilitation end? What literatures can be tapped to address unexpected issues?

This vignette depicts some of the challenges facing OTs involved in the cognitive rehabilitation of people with TBI. TBI is defined as brain damage that disrupts cognitive function in variable ways with diverse consequences (The Merck Manual of Diagnosis and Therapy, 2006). Nearly 1.7 million Americans sustain a TBI each year, prompting 275,000 hospitalizations (Faul, Xu, Wald, & Coronado, 2010). Acutely, TBI severity is assessed using the Glasgow Coma Scale (GCS; Teasdale & Jennett, 1974). GCS scores can be grouped according to TBI severity: mild (13+), moderate (8-12), or severe (<8; Decuypere & Klimo, 2012). GCS scores can be predictive of future cognitive dysfunction, which is associated with future disability (Skandsen et al., 2010). Perhaps, surprisingly, there is no “gold standard” for cognitive rehabilitation (Gordon, 2011) and, consequently, no systematic approach to cognitive remediation. Therapists, of course, use theoretical models to guide interventions, but empirical evidence can help expedite interventions and maximize gains. Without a systematic, evidence-based approach, a patient with TBI may receive varied cognitive interventions until one works, or worse, until reimbursed rehabilitation ends. Cognitive rehabilitation, by nature, results in gains, losses, and plateaus. It is estimated that at least 300 hr of appropriate therapy are needed to promote optimal outcomes. Therefore, it is essential that OT and other therapists use those hours effectively (Leon-Carrion, Dominguez-Morales, Barroso y Martin, & Leon-Dominguez, 2012). In this review, we sought to identify evidence-based cognitive rehabilitation interventions that exist within TBI literature.

Unfortunately, there is no single, uniform TBI literature to support the development of comprehensive best practices. Instead, physicians, nurses, neuropsychologists, therapists, researchers, and other professionals publish relevant findings in field-specific journals. This makes it challenging to stay current with the literature(s). This criticism was highlighted in a recent paper that described the heterogeneity of both TBI patients and TBI literature (Maas et al., 2013). The authors noted that clinical research is often derailed by non-standardized data collection and insufficient multidisciplinary collaboration. The purpose of this article is to summarize relevant findings across the TBI literatures for an OT readership. In short, this review is intended as an “update” for busy OTs conducting cognitive rehabilitation. Our secondary goal is to expand cross talk between related fields as TBI is inherently interdisciplinary and to encourage OTs to promote research that will supply much-needed empirical basis for refining evidence-based practices. We review issues that influence and improve cognitive recovery from the moment of the TBI itself. These topics include successful early medical interventions, assessment, and empirically based cognitive rehabilitation strategies.

There are systematic, broad review papers of evidence-based cognitive rehabilitation (see Carney et al., 1999; Cicerone et al., 2000; Cicerone et al., 2005; Rees, Marshall, Hartridge, Mackie, & Weiser, 2007). This review adds to these papers by focusing on the recent literature and explicitly targeting an audience of OTs. Using the search term TBI cognitive rehabilitation in humans in PubMed, we found 932 articles published between 2006 and 2014. We focus on cognitive rehabilitation for the non-veterans/athletes adult TBI population, and therefore excluded articles specific to other populations, and articles that did not explicitly describe effective cognitive treatment strategies.1 The remaining relevant articles were used to create this review. We also used additional search engines (e.g., Cochrane Library, PEDro, Google Scholar) to ensure that the cognitive rehabilitation section provided as close tocomprehensive coverage of recent empirical articles as possible.

Although grant funding and research programs target TBI in veterans and athletes, our goal was to highlight the consequences of TBI in adult non-veterans/athletes. Recently, falls have replaced motor vehicle accidents as the leading cause of TBI. In the United States, the older adult population is rapidly growing, and older adults are particularly vulnerable to TBI from falls (Wick, 2012). Therefore, it is essential that research also focus on rehabilitation for everyday individuals who sustain TBI. As stated above, our goal was to provide a targeted integration across multiple fields to support OTs engaged in cognitive rehabilitation. At the end of each segment is a brief statement recapitulating the direct relevance of the section to the occupational therapy interventions for TBI. In closing the review, we provide a breakdown of the empirical evidence by cognitive domain to promote our view that increased research is needed. Finally, as a textual note, to avoid excessive qualification (given the variability inherent in TBI), we acknowledge that there can always be exceptions to the general patterns of results described below.

TBI Myths & Facts

Brain injury isn’t like other “conditions” or “injuries.” The severity and effects depend on many things such as:

how old the person was at injury

what part of the brain was injured

how severe the injury was

Everyone’s brain injury is different and the recovery patterns are too. Getting our facts straight is a crucial first step in moving toward the best possible outcomes.

Let’s get our Facts Straight

Myth: Knowing which parts of the brain have been injured will tell you the specific challenges to expect.

By knowing the location of the injury to the brain, you may have some indication of the problems to expect but not to the point of being able to predict specifically what lies ahead. Injury to brain tissue may be much more extensive than just at the site of injury. Every response to brain injury is different.

Fact: With support, many people can change their behavior after a brain injury.

With proper support and therapeutic intervention, many people with brain injury have the ability to change their behavior, learn new things, and lead full and productive lives.

Fact: Many families report that the most challenging problems after brain injury are problems with cognition (learning and thinking) and behavior (emotions and actions).

Cognitive and behavioral problems tend to present the most challenges for families. The good news is that most of these problems can be addressed. You can find many types of support in this website.

Myth: The best way to help a person with brain injury is to assist them with tasks.

As a parent, sibling or spouse of an adult with brain injury, general wisdom suggests that you be there to assist when needed, but avoid offering assistance for activities that can be done independently. Overriding your family member’s efforts (such as jumping in to finish sentences or tasks) lessens a personal sense of dignity, respect and self-worth.

Myth: After a brain injury, a person’s basic emotional needs change.

People with brain injury have the same emotional needs as every other person: to feel loved, to feel useful, to feel needed, to be treated with respect and to exercise control over their lives.

A mild mannered person may tend to become more mild mannered. An aggressive personality may tend to become more difficult and more aggressive after brain injury.

Fact: It is best for a person with a brain injury to be part of any discussion about his or her treatment, care or prognosis even if it will be upsetting.

There is general wisdom that even the most difficult or troubling information should be shared with an adult with a brain injury. Many believe that an adult with a brain injury needs to be a part of EVERY discussion concerning his or her care, treatment, or any plans to help solve personal challenges.

Myth: Most recoveries for brain injury show steady improvement up until 2 years when recovery is complete.

One should expect that there will be inconsistency during the recovery period. A person with a brain injury may be able to do something easily one day, then find the same thing difficult the next day. Although much of the recovery process occurs during the first two years, it is not necessarily complete in 2 years. Recovery can continue throughout a lifetime.

Fact: The amount of time the person with a brain injury remains in a coma is one of the factors that affects recovery.

The amount of time in a coma is one of many factors that will affect recovery. Other factors are
age,

severity of the injury,

where in the brain the injury is located,

early patterns of recovery,

length of time a person is very confused or experiences amnesia,

other injuries to the body, and

the level of health before the injury.

Myth: It is helpful to tell your family member with brain injury that life will return to normal.

It is generally believed that one should not make promises about everything going back to what it was. Every recovery is different and only time will tell what the level of recovery will be. It is more likely that life will have a “new normal”.

Nearly 1.7 million Americans sustain a traumatic brain injury (TBI) each year. These injuries can result in physical, emotional, and cognitive consequences. While many individuals receive cognitive rehabilitation from occupational therapists (OTs), the interdisciplinary nature of TBI research makes it difficult to remain up-to-date on relevant findings. We conducted a literature review to identify and summarize interdisciplinary evidence-based practice targeting cognitive rehabilitation for civilian adults with TBI.

Our review summarizes TBI background, and our cognitive remediation section focuses on the findings from 37 recent (since 2006) empirical articles directly related to cognitive rehabilitation for individuals (i.e., excluding special populations such as veterans or athletes). This manuscript is offered as a tool for OTs engaged in cognitive rehabilitation and as a means to highlight arenas where more empirical, interdisciplinary research is needed.

Nearly 1.7 million Americans sustain a traumatic brain injury (TBI) each year. These injuries can result in physical, emotional, and cognitive consequences. While many individuals receive cognitive rehabilitation from occupational therapists (OTs), the interdisciplinary nature of TBI research makes it difficult to remain up-to-date on relevant findings.